Inspection on 28/02/06 for Talgarth Road

This inspection was carried out on 28th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Talgarth Road 01/12/09

Talgarth Road 05/11/07

Talgarth Road 19/06/06

Talgarth Road 22/08/05

Talgarth Road 21/02/05

Talgarth Road 15/06/04

Talgarth Road 22/03/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Talgarth Road Talgarth Road 41-43 Talgarth Road West Kensington London W14 9DD Lead Inspector Tony Lawrence Unannounced Inspection 28th February 2006 08:55 Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Talgarth Road Address Talgarth Road 41-43 Talgarth Road West Kensington London W14 9DD 020 7603 8607 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hestia Housing Ms Lyris Ofosu Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: Talgarth Road is a registered care home providing personal care and accommodation for up to ten people with mental health support needs. At the time of this inspection, 5 men and 5 women were living in the home and there were no vacancies. The home is managed by Hestia Housing and Support and the building is owned by the Shepherds Bush Housing Association. The home is situated in the West Kensington area with access to local amenities and good transport links. Each service user has his/her own bedroom and shared use of lounges, kitchen, bathrooms and toilets. There is a large garden. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 28th February 2006 from 08:55 am – 12:00 pm. The Inspector spoke with service users, the home’s Deputy Manager and staff. He also saw all communal parts of the home and checked selected care records. The home provides good standards of care and accommodation. Some further work is needed to improve care practice, ensuring that service users are cared for safely. Two of the four requirements made at the last inspection have been met. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The key Standard was met at the last inspection in August 2005. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. The care needs of service users are well assessed and recorded. EVIDENCE: All three key Standards were met at the last inspection in August 2005. During this visit the Inspector checked the care plan files for two people living in the home. Both files were well organised and up to date. Each contained copies of referral forms, care needs assessments and health and social care reports. Care plan reviews and records of key worker sessions were also up to date for both service users. The Inspector saw copies of risk assessments on both files and these were up to date. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17. The home provides varied and nutritious food that is enjoyed by service users. There is a need to review some care practices in the home that can be institutional. EVIDENCE: All five key Standards were met at the last inspection in August 2005. During this visit the Inspector spoke with service users who explained that they are fully involved in menu planning, shopping and cooking meals. Service users who spoke with the Inspector said that they enjoy the food provided in the home and there is a good choice of food. The weekly menu is displayed in the kitchen and this shows that a good variety of nutritious meals are provided. The Inspector felt that staff in the home should review some care practices to make sure that unnecessary restrictions are not imposed on people living in the home. For example, at 10:00 am a service user was told that she could not have access to her personal money until 11:00 am, as staff had not yet checked the balances from the previous day. The service user concerned Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 10 wanted her money so that she could leave for a cookery class that started at 11:00 am. The Inspector felt that this restriction was unnecessary and staff should have been able to give the person her money on request. The practice of only allowing people access to their personal money between 11:00 – 12:00 must be reviewed. Service users also told the Inspector that the kitchen door is locked at night and people are unable to access food in the fridges and cupboards. Unless there are risks to individual’s health and safety, service users should have access to the kitchen at all times and the practice of locking the door must be reviewed. Where risks to health and safety have been identified, these must be supported by risk assessments that are regularly reviewed. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20. The health care needs of people living in the home are well assessed and recorded. Medication is managed safely. EVIDENCE: All three key Standards were met at the last inspection in August 2005. The two care plan files reviewed by the Inspector during this visit each contained very good information about the service user’s mental and physical health care needs. There was evidence on both files of good joint working with psychiatrists and Community Psychiatric Nurses to make sure identified care needs are met by staff in the home and the multi disciplinary team responsible for each person’s care. The Inspector also checked the Medication Administration Record (MAR) sheets for eight people living in the home. The home uses the Boots monitored Dosage System for all prescribed medication and secure storage is provided in a lockable cabinet in the main office. MAR sheets for all eight service users were well maintained and up to date. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. To make sure service users are cared for safely, there is a need to make sure that staff know about and follow local adult protection procedures. EVIDENCE: Key Standard 22 was met at the last inspection in August 2005. Following incidents involving possible misuse of service users’ personal money, Hestia Housing has worked closely with the London Borough of Hammersmith and Fulham and the Commission to review financial management policies and procedures. The Inspector felt that there is still a need to make sure that staff in the home follow the procedures. For example, receipts for expenditure of service users’ money should be numbered and kept with the record sheet completed at the time. This would provide safeguards for service users who will know that their money is managed safely. Staff must also make sure that loans are not given to service users from the home’s petty cash. The last inspection report included a requirement that staff from the home must follow the local authority’s procedures for the protection of vulnerable adults. During this visit the Deputy Manager and staff were unable to find a copy of the local procedures. The Manager must make sure that staff in the home have access to a copy of the procedures and training in how they are to be used. This requirement is repeated from the last inspection and must be implemented without further delay. During the staff handover, a member of staff explained that a service user had an unexplained injury to their foot. Where service users and staff are unable to account for any injury, an accident form must be completed and the person’s social worker must be told. The social worker will then decide if an adult protection meeting is needed. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 13 The last inspection report also included a requirement that staff must notify the Commission of any significant incidents affecting service users’ welfare. During this visit, staff from the home were able to show the Inspector Hestia’s procedures for managing significant incidents. No incidents were recorded in January or February 2006. The procedures include a useful table of the types of incidents that might occur and details of which agencies should be notified in each case. It is a requirement of this report that the checklist is amended to make sure that the Commission is notified of all significant incidents. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 and 30. The home provides a good standard of accommodation that service users are happy with. EVIDENCE: Both key Standards were met at the last inspection in August 2005. During this visit the Inspector spoke with service users about the accommodation and saw all communal parts of the home with a member of staff. Both lounges are comfortably furnished and well decorated. The TV lounge is also used as a smoking room. The home has a sufficient number of bath/shower rooms and toilets. These are located close to service users’ bedrooms and lounges. The kitchen and main office are well equipped. The laundry room / service users’ kitchenette is in need of redecoration / refurbishment. There is a large garden that service users told the Inspector was very well used in the summer. All parts of the home were clean and tidy during this visit. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 34. The home is well staffed to meet the care needs of service users. EVIDENCE: Key Standard 35 was met at the last inspection in August 2005. During this visit the Inspector spoke with the home’s Deputy Manager and one permanent Project Worker and two agency Project Workers. The Inspector felt that this level of staffing was sufficient and staff worked well together to meet the care needs of the existing service users. The Deputy Manager confirmed that he is doing his NVQ Level 4 qualification training; one Project Worker has completed their NVQ Level 3 and two Project Workers are due to complete their Level 3 training later this year. Although the home has not met the target for 50 qualified staff by the end of 2005, the Inspector was satisfied that arrangements are in place to meet this target during 2006. During this inspection the Deputy Manager was not able to find the record of staff Criminal Record Bureau checks. Hestia must provide the Commission with details of CRB checks on all permanent and agency staff working in the home. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 16 Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 and 43. The home is well managed EVIDENCE: Key Standard 39 was met at the last inspection in August 2005. During this visit the Inspector spoke with staff and the home’s Deputy Manager about the day-to-day running of the home. Staff said that they felt well supported and that they worked together well as a team. The home has a full-time permanent Manager who is registered with the Commission. The Inspector discussed two health and safety issues with staff during this visit. The dry food store in the kitchen needs to be cleaned and tidied and containers must be used for open packets of rice, pasta, cereals etc. Staff must also make sure that food is stored at safe temperatures in the home’s fridges and freezers. While the Inspector was in the home, a Team Manager from Hestia Housing arrived to carry out an unannounced monitoring visit. The Deputy Manager confirmed that monitoring visits happen each month and the home and Commission are given a written report after each visit. Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X X X X 2 3 Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA16 Regulation 12 Requirement The practice of only allowing people access to their personal money between 11:00 – 12:00 must be reviewed. The practice of locking the kitchen door at night must be reviewed. Receipts for expenditure of service users’ money should be numbered and kept with the record sheet completed at the time. Staff must make sure that loans are not given to service users from the home’s petty cash. The local authoritys adult protection procedures must be followed consistently. Repeat requirement – original timescale of 31/10/05 not met. The Commission must be informed of any significant issue affecting the welfare of service users. Repeat requirement – original timescale of 31/10/05 not met. Where service users and staff are unable to account for any injury, an accident form must be DS0000019148.V280587.R01.S.doc Timescale for action 31/05/06 2. 3. YA16 YA23 12 17 31/05/06 31/05/06 4. 5. YA23 YA23 17 13 31/05/06 31/05/06 6. YA23 37 31/05/06 7. YA23 37 31/05/06 Talgarth Road Version 5.1 Page 20 8. 9. YA28 YA34 23 19 10. YA42 16 11. YA42 16 completed. The person’s social worker and CSCI must be told of the injury. The laundry room / service users’ kitchenette is in need of redecoration / refurbishment. Hestia must provide the Commission with details of CRB checks on all permanent and agency staff working in the home. The dry food store in the kitchen needs to be cleaned and tidied and containers must be used for open packets of rice, pasta, cereals etc. Staff must also make sure that food is stored at safe temperatures in the home’s fridges and freezers. 31/08/06 30/04/06 30/04/06 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Talgarth Road DS0000019148.V280587.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!